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Epub Mar Long-term results after drug-eluting stent implantation in diabetic patients according to diabetic treatment. Hellenic J Cardiol. Percutaneous coronary intervention in diabetic patients: should choice of stents be influenced? Expert Rev Cardiovasc Ther. Cutlip DE. Percutaneous coronary intervention in patients with diabetes and multi-vessel or left main disease — a review.
Interventional Cardiology. Strategies for multivessel revascularization in patients with diabetes N Engl J Med. Cardiology patient pages. Cardiovascular disease in the diabetic patient. Iatrogenic inpatient hypoglycemia: risk factors, treatment, and prevention. Analysis of current practice at an academic medical center with implications for improvement efforts.
Diabetes Spectrum Oct; 21 4 : Perioperative management of the diabetic patient. Updated June 10, Marks JB. Perioperative management of diabetes. Am Fam Physician. Chronology and determinants of tissue repair in diabetic lower-extremity ulcers. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. Epub Feb 5. Protamine Sulfate Injection. Accessed June 1, Submit Feedback. Email Address. For people with severe aortic stenosis without symptoms, surgery is not always recommended if their quality of life is not affected and their risk for further complications is low.
A new study determined that even when patients have asymptomatic severe aortic stenosis and did not need symptom relief, early surgery was still beneficial because it decreased their risk of death and of People who experienced an in-hospital cardiac arrest in the cardiac catheterization lab were more likely to survive to discharge than those who had a cardiac arrest in the intensive care unit ICU , yet less likely to survive than those who arrested in the operating room OR.
The study protocol was approved by the institutional ethics committee of Beijing Anzhen Hospital, Capital Medical University. Data collection regarding cardiovascular risk factors, clinical variables, medication prescriptions and, laboratory values were conducted based on a review of medical records.
Cardiovascular risk factors included age, gender, diabetes duration, hyperlipidemia, current smoking, hypertension, etc. Clinical variables included contrast media volume, time to PCI, single-vessel disease, infarct-related artery, etc. The medication prescriptions initiated during hospitalization were recorded. The methods for calculating the estimated glomerular filtration rate eGFR and incidence of CI-AKI have been described in other articles and are briefly summarized below [ 2 ].
Then the association between continuous metformin therapy in the perioperative period and incidences of CI-AKI was examined. All statistical studies were carried out using the SPSS The distribution properties of the data were performed using the Kolmogorov-Smirnov test. Baseline characteristics and patient subgroups, depending on the discontinuation of metformin therapy are summarized in Table 1.
There was no statistical difference in both groups for metformin dose. Patients continuing metformin therapy used more beta-blocker. Group 1 patients had cardiovascular risk factors similar to group 2. Clinical factors, including single-vessel disease and infarct-related artery, were also similar for both groups. Delays of management time to PCI , left ventricular systolic function, cTnI peak, and glycosylated haemoglobin HbA1c values were comparable between the two groups Table 2.
Furthermore, no statistical difference was shown in the incidence rate of CI-AKI between the two groups Univariate analysis showed that metformin was irrelevant with the increased incidence of CI-AKI after contrast agent exposure.
Besides, discontinuation of metformin results in interruption of hypoglycemic treatment or change of hypoglycemic regimen, and patients presented glucose fluctuation after admission. T2DM is correlated with poor prognosis in patients who have non-obstructive or obstructive stable coronary artery disease. Recent studies demonstrated that diabetes increase mortality and adverse cardiac outcomes in patients with non-obstructive coronary artery stenosis NOCS -acute myocardial infarction AMI [ 15 , 16 ].
Diabetes may favour the plaque instability in the context of NOCS through pathogenetic mechanisms including inflammation, endothelial dysfunction and coronary vasospasm [ 15 ]. As a first-line drug for T2DM, metformin has been shown to have cardiovascular benefits and fewer adverse reactions [ 17 ]. Current guidelines suggest that prediabetes should also be treated with metformin to mitigate the risk of developing diabetes.
A recent study by Celestino et al. Besides, metformin therapy for prediabetes may improve outcomes by a reduction of inflammatory tone and leptin to adiponectin rate in peri-coronary fat in AMI patients [ 19 ]. There is increasing evidence that specific hypoglycemic drugs with pleiotropic effect on inflammatory tone and oxidative stress may affect the control of atherosclerotic plaque progression in AMI patients [ 15 ]. Hyperglycemic patients presenting with STEMI have higher coronary thrombus burden compared with thrombi from normoglycemic counterparts.
Evidence showed that hyperglycemia causes overproduction of reactive oxygen species and inflammation from thrombus plaque, favouring thrombotic embolization and poor myocardial infarction outcomes.
Advice on the discontinuation of metformin differs between guidelines [ 7 , 8 , 9 , 10 , 22 ]. There are few studies about metformin used in patients with mildly impaired kidney function after the administration of contrast agents.
In the two latest randomized controlled studies, the patients continuing metformin during peri-angiography does not carry the excess risk for renal dysfunction. No lactic acidosis is observed in both studies [ 23 , 24 ]. Those studies strongly suggested that metformin is not related to an increased risk of renal dysfunction after coronary angiography.
The hypothesis that AMI patients may use metformin safely during the peri-angiography period was further reinforced.
Our research is consistent with the above studies. The present data indicated that both absolute and relative creatinine change after PCI were similar between the patients continuing metformin therapy and those suspending metformin therapy.
Several studies have demonstrated that the contrast agent volume is associated with the morbidity of acute kidney injury [ 25 ]. The nephrotoxicity of iodinated contrast media may be proportional to the dose for coronary angiography. The main causes of CI-AKI have been proposed, including renal medullary hypoxia caused by hemodynamic instability, oxidative stress and direct toxicity on kidney tubular epithelial cells [ 26 , 27 , 28 ].
It was important to understand that using a lower dose of contrast agent may substantially reduce the CI-AKI risk of patients. Patients with chronic kidney disease have fewer nephron units than normal, so exposure to the same volume of contrast media will significant increased proportionally. Because of their low adaptive capacity and increased contrast agent exposure, they are more susceptible to develop CI-AKI [ 27 ]. As metformin is eliminated by the kidneys, there are concerns that in patients with the reduced kidney function, the lactic acidosis will be accumulated and precipitated [ 29 ].
However, the strength of the relationship between metformin and lactic acidosis has been dramatically overstated [ 4 ]. Several clinical studies have shown that there is no significant correlation between metformin concentration and lactic acidosis [ 1 , 4 , 30 , 31 , 32 ].
Furthermore, the current study and meta-analyses show that the morbidity of lactic acidosis using metformin is not significantly different from other hypoglycemic treatments, such as sulfonylureas, insulin, and other oral hypoglycemic agents [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ].
Other studies have also shown that metformin concentrations remain in a therapeutic range in mildly to moderately renal impaired patients [ 40 ]. At the same time, growing evidence suggests that the underlying disease associated with the tissue hypoxia rather than metformin use is related to lactic acidosis in diabetes [ 41 , 42 , 43 ].
In the present research, no case of lactic acidosis was observed during hospitalization for both groups. Hyperglycemia has been linked with more complications during hospitalization and poor outcomes in AMI patients. Lazzeri et al. Besides that, another study had also confirmed that acute hyperglycemia is a predictor of CI-AKI and in-hospital mortality [ 45 ].
Peri-procedural tight glycemic control has been shown to significantly increase the area of myocardial salvage following a great recovery of left ventricular function in hyperglycemic patients undergoing emergency coronary intervention for STEMI. These observations strongly suggest that the tight glycemic control at the time of the PCI may be pursued in the STEMI patients to improve their prognosis [ 46 ]. Therefore, strict glucose management in STEMI patients with mildly impaired renal function is recommended during a hospital stay [ 47 ].
In this research, we found the patients who discontinued metformin treatment, were more likely to initiate insulin therapy and had higher peak glycemia. Our data indicated that the patients who stopped metformin were inclined to have blood glucose fluctuation and changes in hypoglycemic regimens after admission. The application of metformin in the peri-angiography period in the existing guidelines is not yet consistent; our study focused on this situation and target at patients who are inclined to develop CI-AKI.
The result of the study indicated that continued use of metformin did not impair renal function compared to discontinuation of metformin during primary PCI period. In real clinical practice, we found that discontinuous use of metformin caused problems in blood glucose management in STEMI patients after admission. The patients who stopped metformin were more likely to have blood glucose fluctuation and changes in hypoglycemic regimens after PCI.
The peak values of fasting and postprandial blood glucose in patients with discontinuous metformin treatment were significantly higher than those of patients receiving metformin continuously. Previous studies have confirmed that peak glycemia during hospitalization is negatively correlated with the long-term survival in diabetic STEMI patients [ 39 ].
To summarize the above findings, continuous use of metformin during coronary angiography may not raise the risk of CI-AKI, and the blood glucose of patients after admission will be better controlled, which is conducive to the prognosis of STEMI patients. This study had the following two limitations. Firstly, it was a retrospective cohort study, conducted at a single centre, based on a relatively small size of populations. Secondly, since the high-risk patients such as those who needed intra-aortic balloon pump, or had respiratory failure were excluded, the results in this paper may not be adapted to these subgroups of patients.
However, it was believed that the findings are of clinical significance in most patients. Risk of lactic acidosis in type 2 diabetes patients using metformin: A case control study.
Consequently, questions have been raised recently regarding the routine discontinuation of metformin, in low-risk patients undergoing coronary angiography. The present study was designed to assess the role of metformin in lactate production in a group of diabetic patients with normal renal function; and to address the questions about significance of routine discontinuation of metformin in low risk patients undergoing coronary angiography.
Iodixanol will be the only contrast media in all patients, because of its low nephrotoxicity. Serum blood urea nitrogen and creatinin; as well as arterial blood gases will be evaluated prior to angiography, and repeated 24 and 48 hours after the procedure.
A written informed consent is taken from all participants and institutional review board has already approved the trial. Drug: Metformin Incidence of lactic acidosis in diabetic patients receiving contrast media in the presence of metformin. Other Name: Glucophage No Intervention: Off-metformin Diabetic patients receiving contrast media with discontinuation of metformin.
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Diabetic patients receiving metformin who were scheduled for:. Patients who had contraindication for metformin administration, such as:. Hide glossary Glossary Study record managers: refer to the Data Element Definitions if submitting registration or results information. Search for terms. Save this study. Warning You have reached the maximum number of saved studies Listing a study does not mean it has been evaluated by the U.
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